Piccolini - nurturing your little ones
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Child's Details
Child's Name
(required)
Surname
(required)
Date of Birth
(required)
Sex
Male
Female
Date of Enrolment
(required)
Ethnicity
If NZ Maori, please state your Iwi affiliation
Home Address
(required)
Home Phone
(required)
Email
(valid email required)
Mother
Mother's Name
(required)
Address
(required)
Email
(valid email required)
Mobile
Home Phone
(required)
Work Phone
(required)
Father
Father's Name
(required)
Address
(required)
Email
(valid email required)
Mobile
Home Phone
(required)
Work Phone
(required)
Guardian
Guardian's Name
Address
Email
(valid email required)
Mobile
Home Phone
Work Phone
I authorise the following person/s to collect my child
Name
Relationship to Child
Phone
Name
Relationship to Child
Phone
Name
Relationship to Child
Phone
Names of people who are forbidden by law to have access to the child OR access with conditions
Legal Papers copied and filed
Yes
No
Emergency Contact Details (If parents are unavailable)
Person's Name
(required)
Address
(required)
Phone Number
(required)
Relationship to Child
(required)
Health Information
Doctor's Name
(required)
Phone number
(required)
Information concerning health / medication / allergies etc.
Details of chronic illnesses and medication required
Is your child immunised? (If so, please provide a copy of immunisation certificate)
Enrolment Information
Days and Times of Enrolment
Monday
8:00am – 4:00pm
Tuesday
8:00am – 4:00pm
Wednesday
8:00am – 4:00pm
Thursday
8:00am – 4:00pm
Friday
8:00am – 4:00pm
Other Information
Names and ages of siblings
Is you child toilet trained?
yes
no
Favourite toy or special routine for rest time
Any particular fears, dislikes etc?
Other comments that you wish to make about your child that would be helpful to staff
20 Hours ECE Details
Is your child receiving Early Childhood Education for up to 6 hours per day, 20 hours per week at this service?
Yes
No
Is your child receiving 20 Hours ECE at any other service?
Yes
No
If yes, you will need to submit and complete an attestation form which is available from Piccolini.
I agree to pay Fees for my child when he/she attends beyond the 6 hours per day or 20 hours per week of ECE (Fees are those hours outside of the 20 hours free. Please ask if you have any queries about these hours)
Yes
No
I agree to pay the following optional charges
Morning and afternoon teas
Sunscreen
High ratio of staff
High quality children's portfolios
Yes
No
Declaration
I agree for my child to be taken on walks in the vicinity of Piccolini
I agree for my child to be taken to the local doctor in the case of an emergency
I have read, understand and agree to abide by Piccolini's Policies
I understand that my child will be taught the Christian meaning of Christmas and Easter and that Christian books and music will be part of the children's library
I give permission for my child’s activities to be observed and recorded under the conditions detailed in the Policy on the Education Program.
I give permission for Arnica cream, Zinc and Caster Oil Cream and Sunscreen to be used on my child at Piccolini if required.
I give permission for my child’s photograph to be taken and used by Piccolini for marketing and educational purposed.
I hereby declare that my child is not enrolled in another Early Childhood institution at the same times that he/she is enrolled at Piccolini.
I have read and understood the fee sheet and agree to abide by these conditions
I agree to accept all WINZ responsibilities and that I will pay in full any amounts not paid by them for this service.
I agree that under the terms of the privacy act (1st July 1993) you irrevocably authorise any person or company to provide us with such information as we may require in response to our credit enquires. That you authorise us to furnish any third party, details of this application and any subsequent dealings that you may have with us as a result of this application being actioned by you.
I agree to pay fees two weeks in advance. If my fees are in arrears for more than two weeks, I understand my child’s place will be withdrawn. Full fees are payable. In default of such prompt payment, you undertake to pay late payment fees of 3% per month on any amount outstanding and to indemnify us and pay all costs and expenses on a solicitor / client base if legal action is necessary, and / or E.C. Credit Control Ltd.’s fees, which may incur in recovering from you any overdue amount.
I agree to provide one months notice prior to withdrawing my child from Piccolini and agree to pay all outstanding fees prior to my departure.
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